Back Pain Guidelines

As an occupational therapist, I have treated back problems and evaluated the results of more than 100 studies for this text: One of the most important causes could be your job.

A question for all those who regularly have back pain exactly where it plagues most people, namely in the lower back: Has your doctor ever talked to you about your abdominal muscles? More precisely, about the lower layer, the transverse abdominal muscles?

No? a pity, but unfortunately no exception. This shows that opportunities are missed in the treatment of back pain. You can get rid of your back pain more easily if you are informed about how it develops and trained in how to deal with it well. This is shown by a study from April 2018. And this also includes that you know which muscles are particularly important for the health of your back.

This text is about how to deal better with back pain. I summarize what more than 100 studies have to say and have looked at guidelines and treatment programs.

I have also dealt with back pain in the past: Privately, because I had some myself for a long time, and professionally, because before I became a journalist, I worked as an occupational therapist with back pain patients. That’s why I know what role our workplace and home furnishings play in the development of back pain. But let’s start all over again.

Back pain is a mysterious debacle.

“Isch hab’ Rücken!” has become a catchphrase since Hape Kerkeling invented his local reporter Horst Schlämmer. Maybe Horst Schlämmer became so successful because the viewers in front of the television sympathize with him? It’s not easy to say how many people in Germany suffer from back pain, but it’s easy to estimate how many of them suffer from sick leave and absenteeism. Here are a few numbers:

The clinical picture of back pain occupies second place among the most frequent diagnoses.

Three out of four people interviewed by the Deutsche Angestellten Krankenkasse (DAK) reported having had back pain in the last twelve months (5,224 people were interviewed).

Every twentieth person in 2017 was at least once on sick leave due to back pain, which corresponds to about six percent of employees.

In every seventh person who had back pain in the last twelve months, it lasted longer than twelve weeks.

Together with other diagnoses affecting the back, back pain costs around 9 billion euros a year (even more, because this figure is from 2008; there are no more recent figures).

However, medical care for patients accounts for only 15 percent, and most costs arise indirectly, e.g. due to days absent from work.

Back pain is not the same as back pain

Back pain is a so-called widespread disease. About 80 percent of Germans have back pain at least once during their lifetime. They usually go away on their own and do not stay longer than six weeks.

This form is called acute, unspecific back pain. Nonspecific means that very often there is no physical change that could explain the pain.

Back pain without a specific cause is characterized by muscle cramps in a certain area of the back. Usually this is the lower back, because this part is particularly quickly overloaded due to lever and shearing forces. Cramped muscles contract and can restrict the space for nerves that emerge between the vertebral bodies.

Then these so-called spinal nerves are “annoyed” by certain movements. Under this stress, some of the affected nerve fibres give the order to contract to the part of the musculature for which they are responsible. This includes the smaller, deep-seated muscles of the back and the surrounding tissue sheaths, the fasciae. Other spinal nerve fibres transmit a pain stimulus that comes from the musculature when it is too tense due to the nerval continuous fire. This results in a feedback effect in which even more pressure is built up on the sensitive nerves – the muscle cramping and pain become even stronger.

The unspecific, acute back pain then becomes a bigger problem if it lasts longer than twelve weeks. Then it is called chronic. About five to seven percent of back pain patients develop such chronic pain. This corresponds to about every fifth woman (22 percent) and every sixth man (15 percent) with back pain episodes.

Particularly fatal: Many people who feel chronic pain in their lower back give up hope during the course of treatment that they can get rid of their pain again. They are often treated for years, and some even undergo surgery without the pain disappearing.

In many patients, the X-ray or MRI image is inconspicuous. That is why at some point they believe what unsuccessful treatments suggest: That they have to come to terms with their pain, that everything is only psychological, that they perhaps only imagined the complaints and that they will probably have to rely on painkillers all their lives.

There are good reasons to be confident. First of all, you can do something yourself to ensure that the back pain attacks do not become a permanent condition. And secondly, there are treatment programmes that are proven to work better than others.

The most important information about back pain at a glance

What we know

Back pain is the second most common disease in Germany. We know that exercise and behavioural changes are the best ways to reduce pain and movement restrictions. We know the risk factors that contribute to the development of chronic back pain and which treatment programs work better than others.

What we don’t know

Most back pain is non-specific, which means we do not know what causes the pain.

What this means for you

If you have back pain, you should stay active and not spare yourself for a long time, because this increases the risk of chronic back pain.

If you already have chronic back pain, you can ask your doctor to check whether a special therapy programme is suitable for you: interdisciplinary multimodal pain therapy.

What this means for health policy

Although a national care guideline provides evidence-based treatment recommendations, too often back pain patients are not treated according to the recommendations. Health insurance policies contribute to this and should be more based on medical facts. Doctors should use less imaging for back pain patients, talk more about meaningful behavioural changes and pay more attention to risk factors for chronic pain.

When back pain can become chronic

Many experts puzzle: Why do more and more people have back pain? In 2003, two out of four people said they had had back pain in the last twelve months, but now it’s three out of four. And also the hospital treatments increased: since 2006 by 98,000 cases to now 222,000. That is an increase by 80 per cent. This means that every third hospital case is now a back pain patient.

But by no means everyone goes to the doctor with their complaints, namely only one in three patients. Many first try to cope with the pain on their own.